Location
Moultrie, GA
Start Date
9-5-2023 1:00 PM
End Date
9-5-2023 4:00 PM
Description
Background: According to the Centers for Disease Control (CDC), venous thromboembolisms affect 900,000 people and cause up to 100,000 deaths yearly. A less common subset of these cases includes those of which the emboli, though originating in venous vasculature, are able to pass through intracardiac defects, including a patent foramen ovale (PFO). PFOs are relatively common in the general population, with an incidence of approximately 20-30%. Though oftentimes asymptomatic, PFOs may present an opportunity for an embolism to bypass the lungs and utilize a more direct route to the systemic circulation, otherwise known as paradoxical embolism. One feared complication of a paradoxical embolus is an increased risk of stroke or transient ischemic attack (TIA).
Case Presentation: This report describes a case of an 82-year-old female with a past medical history of hyperlipidemia, hypertension, heart failure with preserved ejection fraction (HFpEF), and stroke presented to the emergency room with altered mental status and significant hypotension. Her initial workup revealed a mildly elevated troponin of 0.46 ng/mL, a myoglobin of 80 ng/mL, an unremarkable EKG, and a normal head CT. She was subsequently admitted to determine the etiology of her ED presentation. A transthoracic echocardiogram (TTE) suggested a left atrial myxoma or a mobile mass in the right atrium. A transesophageal echocardiogram (TEE) was then performed for better visualization and revealed an approximately 4.4 cm paradoxical thrombus entrapped in a PFO. She was subsequently anticoagulated with IV heparin. Further evaluation revealed septic shock secondary to acute cystitis. It was determined that the paradoxical embolus entrapped in the PFO was an incidental finding unrelated to her clinical presentation. Upon medical stabilization, the patient was discharged on Eliquis 2.5 mg PO twice daily for anticoagulation with discontinuation of heparin. The patient was instructed to follow up with cardiology upon discharge. Though this patient was fortunate to avoid a stroke or TIA during this hospitalization, the entrapped clot poses a significant risk for future embolization without medical intervention.
Discussion: Studies have revealed a prevalence of PFO in 16-73% of stroke patients, highlighting the significance of such findings. Clinicians can utilize the RoPE score (Risk of Paradoxical Embolism), which includes various risk factors, including hypertension and diabetes mellitus, to stratify a PFO’s risk of causing a paradoxical stroke. A RoPE score of greater than 7 suggests a patient may benefit from PFO closure.
Conclusion: This case illustrates the significance of PFOs and the potential risk of stroke or TIA that may arise.
Embargo Period
7-11-2023
Included in
Paradoxical embolism entrapped in a patent foramen ovale
Moultrie, GA
Background: According to the Centers for Disease Control (CDC), venous thromboembolisms affect 900,000 people and cause up to 100,000 deaths yearly. A less common subset of these cases includes those of which the emboli, though originating in venous vasculature, are able to pass through intracardiac defects, including a patent foramen ovale (PFO). PFOs are relatively common in the general population, with an incidence of approximately 20-30%. Though oftentimes asymptomatic, PFOs may present an opportunity for an embolism to bypass the lungs and utilize a more direct route to the systemic circulation, otherwise known as paradoxical embolism. One feared complication of a paradoxical embolus is an increased risk of stroke or transient ischemic attack (TIA).
Case Presentation: This report describes a case of an 82-year-old female with a past medical history of hyperlipidemia, hypertension, heart failure with preserved ejection fraction (HFpEF), and stroke presented to the emergency room with altered mental status and significant hypotension. Her initial workup revealed a mildly elevated troponin of 0.46 ng/mL, a myoglobin of 80 ng/mL, an unremarkable EKG, and a normal head CT. She was subsequently admitted to determine the etiology of her ED presentation. A transthoracic echocardiogram (TTE) suggested a left atrial myxoma or a mobile mass in the right atrium. A transesophageal echocardiogram (TEE) was then performed for better visualization and revealed an approximately 4.4 cm paradoxical thrombus entrapped in a PFO. She was subsequently anticoagulated with IV heparin. Further evaluation revealed septic shock secondary to acute cystitis. It was determined that the paradoxical embolus entrapped in the PFO was an incidental finding unrelated to her clinical presentation. Upon medical stabilization, the patient was discharged on Eliquis 2.5 mg PO twice daily for anticoagulation with discontinuation of heparin. The patient was instructed to follow up with cardiology upon discharge. Though this patient was fortunate to avoid a stroke or TIA during this hospitalization, the entrapped clot poses a significant risk for future embolization without medical intervention.
Discussion: Studies have revealed a prevalence of PFO in 16-73% of stroke patients, highlighting the significance of such findings. Clinicians can utilize the RoPE score (Risk of Paradoxical Embolism), which includes various risk factors, including hypertension and diabetes mellitus, to stratify a PFO’s risk of causing a paradoxical stroke. A RoPE score of greater than 7 suggests a patient may benefit from PFO closure.
Conclusion: This case illustrates the significance of PFOs and the potential risk of stroke or TIA that may arise.